pleural effusion

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jok200

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My understanding is that once a pleural effusion is identified or suspected on chest x-ray the fluid amount is measured( not sure how that is exactly done) then if it is above a certain amount then it is tapped via thoracentesis. (is this correct?) The ct-scan is used for large effusions? I am unsure of the role of the ct-scan in pleural effusions because even if the effusion is loculated wouldn't I still have to tap it anyway?

thanks again, spent a great deal of time trying to look this up but I had trouble finding definitive answers.

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My understanding is that once a pleural effusion is identified or suspected on chest x-ray the fluid amount is measured( not sure how that is exactly done) then if it is above a certain amount then it is tapped via thoracentesis. (is this correct?) The ct-scan is used for large effusions? I am unsure of the role of the ct-scan in pleural effusions because even if the effusion is loculated wouldn't I still have to tap it anyway?

thanks again, spent a great deal of time trying to look this up but I had trouble finding definitive answers.

That's because there are not great definitive answers out there, hell even the guidelines as much as you're able to find any are as vague as possible. Everyone agrees if it's infected you need to drain it, but that's about it. You don't always go after a pleural effusion, but if you think it's clinically indicated or the patient is symptomatic you put a needle in it to see what's in the fluid and send it for cultures and cytology. There is no reason to use a CT scanner for effusions and drainage in general. Put an ultrasound on the patient yourself, find the fluid, and put a needle in it. If you insist on putting a needle (or tube) into a loculated effusion, instead of simply asking the surgeons to deal with it, then sometimes it's helpful to use the CT to get the needle/tube into the biggest loculation.
 
So.... you do chest xray and an effusion is identified, if you can explain it based on the clinical picture of the patient (he has chf, cirrhosis) and presents with bilater pleural effusions then their is no need to tap what is probably a transudate effusions unless something clinically suggests otherwise. In another instance you see an air fluid level on chest xray in an elderly patient with multiple comorbids you could make the argument he aspirated and the air fluid level is produced by an anaerobe or gas producing organism and may be an empyema in which case you must drain the fluid. If its an empyema it may be loculated so doing the ct scan can further evaluate the effusion and where best to stick the needle in that case. Does all this sound correct, since whether or not to tap an effusion is more a clinical decision than specific guidelines.

thanks again-
 
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So.... you do chest xray and an effusion is identified, if you can explain it based on the clinical picture of the patient (he has chf, cirrhosis) and presents with bilater pleural effusions then their is no need to tap what is probably a transudate effusions unless something clinically suggests otherwise. In another instance you see an air fluid level on chest xray in an elderly patient with multiple comorbids you could make the argument he aspirated and the air fluid level is produced by an anaerobe or gas producing organism and may be an empyema in which case you must drain the fluid. If its an empyema it may be loculated so doing the ct scan can further evaluate the effusion and where best to stick the needle in that case. Does all this sound correct, since whether or not to tap an effusion is more a clinical decision than specific guidelines.

thanks again-

Getting better. The guidelines SUCK. Poor Richard Light, I know they tried to do their best :laugh: I hear he's a pretty cool guy and would probably agree.

Anyway, if you have a patient with CHF and cirrhosis with effusion, no real need to tap unless they are SOB or are having other pulmonary symptoms consistent with a pulmonary infection, or if you think their heart or liver disease isn't bad enough to explain the effusion. Then put a needle in it.

If you put a needle in it and it's exudative then you need to try and figure out why, though sometimes this can be difficult.

If the effusion is infected, either you get a positive gram stain for bugs, or frank purulence when you put in your needle. That patient needs a chest tube. If the effusion looks free-flowing on U/S no need for the chest CT and IR to place anything. If the effusion looks "funny" on bedside U/S, get the chest CT. If the effusion looks loculated on chest CT asked the surgeons for an opinion +/- IR placement of tube.
 
Whenever there is a pleural effusion I always think about thoracentesis (because I think they're the best bedside procedure) and remember it is diagnostic and therapeutic... but also risky and something I don't want to expose someone to unless it's relieving something therapeutically (large volume, impairing breathing) or telling something significant diagnostically (cytology for cancer dx or staging, transudate vs exudate). For risk have to think of if there is enough fluid realistically for studies without giving someone a pneumothorax and buying them a chest tube.

As with everything there is the option to do nothing or just use medicine to manage fluid if you think it's transudative from CHF/Cirrhosis, but remember if you have any reason to believe it's pus/exudative you should clean it out because as with many places in the body having a bunch of pus hanging around rotting isn't the greatest thing as far as outcomes such as empyema that sets up and basically puts a patient's lung out of service.
 
Whenever there is a pleural effusion I always think about thoracentesis (because I think they're the best bedside procedure) and remember it is diagnostic and therapeutic... but also risky and something I don't want to expose someone to unless it's relieving something therapeutically (large volume, impairing breathing) or telling something significant diagnostically (cytology for cancer dx or staging, transudate vs exudate). For risk have to think of if there is enough fluid realistically for studies without giving someone a pneumothorax and buying them a chest tube.

As with everything there is the option to do nothing or just use medicine to manage fluid if you think it's transudative from CHF/Cirrhosis, but remember if you have any reason to believe it's pus/exudative you should clean it out because as with many places in the body having a bunch of pus hanging around rotting isn't the greatest thing as far as outcomes such as empyema that sets up and basically puts a patient's lung out of service.

You don't always have to drain it. Needle into to get enough fluid for studies is often enough.

I do this all the time with patient's on a vent with new opacity and effusion that I don't want to fool around with the whole centesis kit. 18g needle and a 20cc syringe.
 
You don't always have to drain it. Needle into to get enough fluid for studies is often enough.

I do this all the time with patient's on a vent with new opacity and effusion that I don't want to fool around with the whole centesis kit. 18g needle and a 20cc syringe.

I actually do this for therapeutic as well as diagnostic thoras. 4-Fr. soft catheter advanced over a needle, attached to extension tubing/3 way stopcock and hooked up to a vacutainer bottle. I never use the big kits, those things are :scared:.

I find the small catheters are much easier to deal with than all the stuff that comes in the kits we have around the hospital.
 
I actually do this for therapeutic as well as diagnostic thoras. 4-Fr. soft catheter advanced over a needle, attached to extension tubing/3 way stopcock and hooked up to a vacutainer bottle. I never use the big kits, those things are :scared:.

I find the small catheters are much easier to deal with than all the stuff that comes in the kits we have around the hospital.

Yeah, you guys have the cooler toys. On the floor it either centesis kit or needle and syringe. Though, I guess I've gotten kind of used to the big, long needles now.
 
Could someone explain the difference between a complicated para-pneumonic effusion and an empyema? Is it just that empyema has a lot more bacteria so it has a pus-like fluid? Many thanks in advance!
 
Could someone explain the difference between a complicated para-pneumonic effusion and an empyema? Is it just that empyema has a lot more bacteria so it has a pus-like fluid? Many thanks in advance!
Empyema = positive culture/gram stain. That's usually the hard distinction. Theres some gray area in there so if the fluid studies look horrible, you want to clean that space out regardless of whether the gram stain is positive.
 
Empyema = positive culture/gram stain. That's usually the hard distinction. Theres some gray area in there so if the fluid studies look horrible, you want to clean that space out regardless of whether the gram stain is positive.
No. At least not by any of Light's papers.

Empyema is frank pus. It needs to look frankly purulent before it can be called an "empyema".

A complicated parapneumonic effusion is a parapneumonic effusion with a positive gram stain, culture, pH under 7.2, glucose under 60. That is, a positive gram stain/culture just makes a parapneumonic effusion "complicated", it doesn't make it an empyema.

The difference being an empyema needs surgery, vs a complicated parapneumonic effusion can usually be treated with just a chest tube (+/- TPA/DNAase if you there's loculations and you really want to avoid surgery).
 
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I'm not sure that the distinction between complicated parapneumonic effusion and empyema are consistent across sources. The presence of frank pus defines empyema, but both complicated parapneumonic effusion and empyema can have positive Gram stain/culture.

I'm also not convinced that this distinction matters, as management isn't different. Antibiotics and chest tube drainage apply to both. If fails, surgery.
 
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